Nutritional Assessment Form PDF Details

The Nutritional Assessment form, known as the Mini Nutritional Assessment (MNA®), serves as a comprehensive tool designed to identify individuals at risk of malnutrition and those who are already malnourished. Developed with the backing of research and validated through extensive studies, the MNA® incorporates a variety of parameters aimed at evaluating an individual's nutritional status. Initially, it begins with a screening section that covers aspects such as changes in food intake, weight loss, mobility, psychological stress, neuropsychological problems, and body mass index (BMI). Depending on the results, which are quantified through a scoring system, individuals are categorized into normal nutritional status, at risk of malnutrition, or malnourished. For those scoring 11 or less, the assessment continues to a more detailed evaluation that includes questions on living situation, prescription drug use, presence of pressure sores or skin ulcers, dietary habits including meal frequency, protein, fruit and vegetable intake, hydration levels, mode of feeding, self-perception of nutritional and health status, and physical measurements like mid-arm and calf circumference. This dual-phase approach, combining initial screening with further in-depth assessment, ensures a thorough analysis of an individual's nutritional health, guiding healthcare professionals in developing appropriate care plans. Such a well-structured form, backed by studies from reputable sources and supported by Nestlé, underscores the importance of nutrition in overall health, especially among the elderly, making the MNA® a critical instrument in geriatric healthcare management.

QuestionAnswer
Form NameNutritional Assessment Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesonline nutrition questionnaire, assessment mna, sample questionnaire for nutritional assessment, assessment mini mna

Form Preview Example

Mini Nutritional Assessment

MNA®

 

Last name:

 

First name:

 

 

 

 

 

 

 

 

 

 

 

Sex:

Age:

Weight, kg:

Height, cm:

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete the screen by filling in the boxes with the appropriate numbers. Add the numbers for the screen. If score is 11 or less, continue with the assessment to gain a Malnutrition Indicator Score.

Screening

AHas food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

0 = severe decrease in food intake

1 = moderate decrease in food intake

2 = no decrease in food intake

BWeight loss during the last 3 months 0 = weight loss greater than 3kg (6.6lbs) 1 = does not know

2 = weight loss between 1 and 3kg (2.2 and 6.6 lbs) 3 = no weight loss

CMobility

0 = bed or chair bound

1 = able to get out of bed / chair but does not go out

2 = goes out

DHas suffered psychological stress or acute disease in the

past 3 months?

0 = yes 2 = no

ENeuropsychological problems

0 = severe dementia or depression

1 = mild dementia

2 = no psychological problems

FBody Mass Index (BMI) (weight in kg) / (height in m2) 0 = BMI less than 19

1 = BMI 19 to less than 21

2 = BMI 21 to less than 23

3 = BMI 23 or greater

Screening score

(subtotal max. 14 points)

12-14 points:

Normal nutritional status

8-11 points:

At risk of malnutrition

0-7 points:

Malnourished

For a more in-depth assessment, continue with questions G-R

Assessment

GLives independently (not in nursing home or hospital)

1 = yes 0 = no

HTakes more than 3 prescription drugs per day

0 = yes 1 = no

IPressure sores or skin ulcers

0 = yes 1 = no

Ref. Vellas B, Villars H, Abellan G, et al. Overview of MNA® - Its History and Challenges. J Nut Health Aging 2006; 10: 456-465.

Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for Undernutrition in Geriatric Practice: Developing the Short-Form Mini Nutritional Assessment (MNA-SF). J. Geront 2001; 56A: M366-377.

Guigoz Y. The Mini-Nutritional Assessment (MNA®) Review of the Literature – What does it tell us? J Nutr Health Aging 2006; 10: 466-487.

®Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners © Nestlé, 1994, Revision 2006. N67200 12/99 10M

For more information: www.mna-elderly.com

JHow many full meals does the patient eat daily?

0 = 1 meal

1 = 2 meals

2 = 3 meals

KSelected consumption markers for protein intake

•At least one serving of dairy products

(milk, cheese, yoghurt) per day

yes

no

•Two or more servings of legumes

 

or eggs per week

yes

no

•

Meat, fish or poultry every day

yes

no

0.0= if 0 or 1 yes

0.5= if 2 yes

1.0 = if 3 yes

.

LConsumes two or more servings of fruit or vegetables per day?

0 = no 1 = yes

MHow much fluid (water, juice, coffee, tea, milk...) is consumed per day?

0.0= less than 3 cups

0.5= 3 to 5 cups

1.0 = more than 5 cups

.

NMode of feeding

0 = unable to eat without assistance

1 = self-fed with some difficulty

2 = self-fed without any problem

OSelf view of nutritional status

0 = views self as being malnourished

1 = is uncertain of nutritional state

2 = views self as having no nutritional problem

P In comparison with other people of the same age, how does the patient consider his / her health status?

0.0= not as good

0.5= does not know

1.0= as good

2.0 = better

 

.

Q Mid-arm circumference (MAC) in cm

0.0= MAC less than 21

0.5= MAC 21 to 22

1.0 = MAC 22 or greater

.

R Calf circumference (CC) in cm

0

= CC less than 31

 

1

= CC 31 or greater

 

Assessment (max. 16 points)

.

Screening score

.

Total Assessment (max. 30 points)

.

Malnutrition Indicator Score

24 to 30 points

normal nutritional status

17 to 23.5 points

at risk of malnutrition

Less than 17 points

malnourished

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1. Complete your nutritional assessment questionnaire with a selection of major blanks. Note all of the important information and be sure nothing is missed!

Stage number 1 for filling out cie food and nutrition assessment report forms pdf

2. After this array of fields is completed, you have to put in the required particulars in A B C D E F, Has food intake declined over the, Screening score subtotal max, Normal nutritional status At risk, Assessment, Lives independently not in nursing, if or yes if yes if yes, and Assessment max points Screening so you can proceed to the third stage.

Part # 2 for submitting cie food and nutrition assessment report forms pdf

3. In this stage, look at Ref, Vellas B Villars H Abellan G et al, Malnutrition Indicator Score, to points, to points, Less than points, normal nutritional status, at risk of malnutrition, and malnourished. Every one of these will have to be filled in with greatest focus on detail.

Filling in part 3 in cie food and nutrition assessment report forms pdf

Many people frequently make mistakes while filling out normal nutritional status in this section. Don't forget to read again everything you type in here.

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